HESI RN
HESI 799 RN Exit Exam Quizlet
1. The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?
- A. Hoarse voice
- B. Slight difficulty swallowing
- C. Positive Chvostek's sign
- D. Pain at the incision site
Correct answer: C
Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.
2. Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?
- A. Maintain cold packs on the perineum for 24 hours.
- B. Assess the client's pain level frequently.
- C. Observe for appropriate interaction with the infants.
- D. Assess fundal tone and lochia flow.
Correct answer: D
Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.
3. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Hemoglobin
- C. White blood cell count
- D. Serum creatinine
Correct answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.
4. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Perform deep suctioning every 2 to 4 hours.
- B. Encourage the client to drink plenty of fluids.
- C. Increase humidity in the client's room.
- D. Administer a mucolytic agent.
Correct answer: C
Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.
5. An 80-year-old male client with multiple chronic health problems becomes disoriented, agitated, and combative 24 hours after being admitted to the hospital. What nursing intervention is most important to include in this client's plan of care?
- A. Request a psychiatric consultation for the client.
- B. Reorient the client frequently to time, place, and person.
- C. Administer prescribed antipsychotic medications to reduce agitation.
- D. Obtain an order for a sitter to stay with the client.
Correct answer: B
Rationale: Reorienting the client frequently is the most important nursing intervention in this scenario. It helps reduce confusion and agitation, which are common symptoms of acute delirium in hospitalized elderly clients. Requesting a psychiatric consult (choice A) may be necessary if the reorientation does not improve the client's condition or if there are underlying psychiatric concerns, but reorientation should be attempted first. Administering antipsychotic medications (choice C) should not be the initial intervention as they can have adverse effects in elderly individuals. Obtaining a sitter (choice D) may provide support but does not directly address the client's disorientation and agitation.
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